Janeen Wright: The Case

Chief Complaint: trouble walking

Janeen Wright is a 73-year-old woman who is coming to her primary care office for numbness and weakness of her left leg. It’s hard for her to tell exactly when the problem started, but she thinks she first noticed it a few months ago and says she has now fallen a couple of times while walking because her left leg “just kind of gave out on me” while she was walking. Both legs “feel funny, kind of stiff and clumsy,” but the left leg is definitely worse than the right. She usually walks a few miles a day for exercise but has been afraid to for the last several weeks.

She has a history of back pain due to degenerative disk disease for which she takes Tylenol as needed, and says her back has been acting up more lately, requiring her to use a heating pad to sleep at night.

When asked about bladder or bowel changes, she says she has been more constipated than usual and has had to take some Milk of Magnesia. Her bowel movements have been soft, the usual size, and there is no blood in them/color change when they do occur. She has some baseline urinary dribbling “when she waits too long to pee” and doesn’t think this is different.

Past Medical History:

Degenerative disk disease seen on MRI in 2008, treated with physical therapy and acetaminophen

Stage 3 breast cancer treated with mastectomy and chemotherapy in 2012, in remission, now on Arimidex, followed by oncology annually

Chronic kidney disease, stage 3, followed by nephrology

renal osteodystrophy, also followed by nephrology, taking cholecalciferol and calcium acetate

Hypertension, also followed by nephrology, currently taking furosemide, amlodipine, and lisinopril

Total knee replacement on left for osteoarthritis in 2004

Exam:

T

98.4

HR

72

BP

135/75

RR

12

SpO2

99%

GEN: awake, alert, pleasant

HEENT: mucus membranes moist, good dentition, pharynx and TM’s normal, neck has full range of motion without pain

Motor: no dysdiachokinesia of upper extremities, DTR’s 2+ in upper extremities and right lower extremity, 3+ in left patellar and 4+ in left Achilles, 5/5 strength in all 4 except 4/5 strength in iliopsosas mm. Left foot toes flare out when sole of foot is stroked from heel to toe. Walks with stiff legs and appears unsteady on gait testing.

Sensory: Pain sensitivity decreased on right body below umbilicus. Position sense and temperature perception decreased on left leg and foot.

By close of day 1, please create:

A complete list of the abnormalities seen in this case and an an initial guess about where in the neuroaxis each of these may localize. Your ability to do this may be limited at this point; if not enough is known, create learning objectives that encompass this need

A differential diagnosis for the root cause of this patient’s problem; if not enough is known about some of the factors in the case to fully flesh out this differential, create learning objectives that address this gap

A diagnostic workup you would like to order to narrow this differential diagnosis to a final diagnosis. Place these tests in the order in which you think they should be done, keeping in mind cost-effectiveness and utility to the patient. For each test you order, articulate how it will help you/help the patient. Your tutor will be able to give you the results of some tests at the next PBL session.